Therapeutic strategies for managing hemorrhagic moyamoya disease (MMD) remain controversial. In this study, we investigated the optimal therapy for hemorrhagic MMD. In accordance with the PRISMA statement, we searched through relevant articles and references from PubMed, Embase, and Cochrane database, and performed a network meta-analysis using R version 3.4.4 software. A total of 9 articles (including 1050 patients) were included in our analysis. Of these 1050 patients, 557 underwent surgical revascularization (including direct and indirect bypass), and the remaining 493 patients were managed with a conservative treatment regimen. A pooled analysis revealed that surgical revascularization was superior to the conservative treatment regimen in decreasing the rate of recurrent stroke events (odds ratio [OR], 0.39; 95% confidence interval [CI], 0.24-0.65), including ischemic stroke recurrence (OR, 0.31; 95% CI, 0.12-0.79) and hemorrhage recurrence (OR, 0.45; 95% CI, 0.26-0.79), but not in reducing mortality (OR, 0.53; 95% CI, 0.24-1.17). Moreover, the incidence of recurrent stroke in the direct bypass cohort was lower than that for either the conservative treatment cohort (OR, 0.30; 95% CI, 0.15-0.58) or the indirect bypass cohort (OR, 0.39; 95% CI, 0.18-0.87). However, the ratios showed no statistically significant difference between the latter 2 cohorts (OR, 0.75; 95% CI, 0.33-1.68). Surgical revascularization, especially a direct bypass regimen, may be the optimal strategy for treating hemorrhagic MMD. Copyright © 2018 Elsevier Inc. All rights reserved.